Dartmouth-Hitchcock Research Contributes to Recommendations on Lung Cancer Screening
July 31, 2013
by Donna Dubuc
In a long-awaited opinion, the U.S. Preventive Services Task Force (USPSTF) has announced draft recommendations in support of lung cancer screening for those facing the highest risk of lung cancer in a paper published in Annals of Internal Medicine. The announcement constitutes a reversal of opinion for the Task Force, which in 1996 recommended against screening for lung cancer and reached that conclusion again in 2004.
The draft recommendations come two years after new research showed that lung cancer screening with low-dose computed tomography (CT) reduced deaths from lung cancer by 20 percent. The announcement immediately follows the release of a technical report produced by the Cancer Intervention and Surveillance Modeling Network (CISNET), a consortium of National Cancer Institute (NCI) sponsored investigators who use statistical modeling to improve public health.
Study data supports change in clinical practice
Dartmouth-Hitchcock radiologist William C. Black, MD served as an advisor to the CISNET consortium and co-authored the paper just published. Black helped CISNET understand data gathered in a ten-year study he helped design called the National Lung Screening Trial (NLST), which provided much of the data supporting this change in clinical practice.
In addition to helping design the NLST, Black - director of chest imaging at Dartmouth-Hitchcock and also a professor of radiology and of community and family medicine at Dartmouth's Geisel School of Medicine and a member of Dartmouth-Hitchcock's Norris Cotton Cancer Center - served on its executive committee and was principal investigator for the trial at Dartmouth-Hitchcock Medical Center. Black's firsthand experience as a radiologist who conducted a decade of lung cancer screens allowed him to offer clinical knowledge about the principles of chest radiology to CISNET.
"CISNET's modeling showed that the most effective screening methods were annual screening," said Black. "At the conclusion of NLST, we didn't know what age groups should be offered screening or how frequently it should be performed."
"Balance of benefits and harms" in screening
The Task Force determined that a reasonable balance of benefits and harms is obtained by annually screening people who are 55 through 79 years old with a 30 pack years or greater history of smoking, who are either current smokers or have quit in the past fifteen years.
This approach to screening is very close to the one used by the NLST, an NCI-funded randomized clinical trial published in the New England Journal of Medicine in 2011.
It consisted of three annual screenings, and compared screening with low-dose CT to screening with a single view chest X-ray. More than 53,000 current or former heavy smokers, ages 55 to 74, enrolled in study centers across the country.
The USPSTF recommends that patients be informed of the benefits and harms of screening and actively participate in the decision to be tested. "This is a huge, significant change," said Black. "Instead of taking an approach that everyone good or bad should be screened across the board, this calls on people to form preferences and have input on the decision." According to Black this move is an important achievement for The Dartmouth Institute, which advocates for shared decision making in medicine.
Development of decision aids and shared decision making
Over the past 2 years, Black has co-chaired Norris Cotton Cancer Center's Lung Cancer Screening Working Group. Black championed the idea of including decision aids for patients undergoing lung cancer screening and with the help of fellow Dartmouth researchers Lisa Schwartz, MD, and Steve Woloshin, MD at the Dartmouth Institute for Health Policy & Clinical Practice (TDI) created a patient and physician guide to explain the results of NLST. They went on to create another guide (PDF) for Dartmouth-Hitchcock that more specifically focused on the decision about whether to be screened with chest CT.
The USPSTF recommendations are consistent with those offered by other professional organizations. The American College of Chest Physicians and American Society of Clinical Oncology jointly published evidence-based practice guidelines in 2012 about who is eligible for lung cancer screening and how and where it should be performed.
Major medical societies recommend annual lung cancer screening be conducted at medical centers with access to multi-disciplinary lung cancer diagnosis and treatment. Since the first scan can lead to other testing, guidelines stress the importance of being screened at a center that has a comprehensive process for the interpretation, evaluation, and treatment of any potential findings, including lung cancer. Dartmouth-Hitchcock's Lung Cancer Screening service is part of Norris Cotton Cancer Center, one of only 41 NCI-designated comprehensive cancer centers.
Screening is not an alternative to smoking cessation. Research suggests that the absolute risks of continuing to smoke are large, and the absolute benefits of cessation also are large. Current smokers interested in CT screening for lung cancer are encouraged to seek smoking cessation counseling. Dartmouth-Hitchcock provides patients and families with support and tools to quit smoking, including referral to tobacco cessation clinics of anyone over the age of 18 who wants to end their dependence on tobacco.
Dartmouth-Hitchcock is a national leader in patient-centered health care and building a sustainable health system. Founded in 1893, the system includes New Hampshire's only Level 1 trauma center and its only air ambulance service, as well as the Norris Cotton Cancer Center, one of only 41 National Cancer Institute-designated Comprehensive Cancer Centers in the nation, and the Children's Hospital at Dartmouth-Hitchcock, the state's only Children's Hospital Association-approved, comprehensive, full-service children's hospital. As an academic medical center, Dartmouth-Hitchcock provides access to nearly 1,000 primary care doctors and specialists in almost every area of medicine, as well as world-class research at the Audrey and Theodor Geisel School of Medicine at Dartmouth.